How Far Do Umbilical Hernia Repair Meshes Extend

Ulus Cerrahi Derg. 2022; 31(3): 157–161.

Current options in umbilical hernia repair in adult patients

Received 2022 Oct 28; Accepted 2022 Dec 7.

Abstract

Umbilical hernia is a rather common surgical problem. Elective repair after diagnosis is advised. Suture repairs have high recurrence rates; therefore, mesh reinforcement is recommended. Mesh tin can be placed through either an open or laparoscopic approach with good clinical results. Standard polypropylene mesh is suitable for the open onlay technique; still, composite meshes are required for laparoscopic repairs. Large seromas and surgical site infection are rather common complications that may upshot in recurrence. Obesity, ascites, and excessive weight gain post-obit repair are manifestly potential risk factors. Moreover, smoking may create a chance for recurrence.

Keywords: umbilical hernia, hernia repair, mesh, laparoscopy

INTRODUCTION

Umbilical hernia is a rather mutual surgical problem. Approximately 10% of all primary hernias incorporate umbilical and epigastric hernias (ane). Approximately 175,000 umbilical hernia repairs are annually performed in the US (2). It has been reported that the share of umbilical and paraumbilical hernia repairs among all repairs for abdominal wall hernias increased from 5% to fourteen% in UK in the last 25 years (three). A similar rise has been reported in a contempo multicenter study from Turkey (four).

In full general, umbilical hernias are more than common in women than men; however, there are series in which male patients are more frequent (v). Typically, a lump is observed around the omphalus. Pain is the almost common indication to visit a physician and undergo a repair (6). Recurrence may develop even in cases where a prosthetic mesh is used. Recurrent umbilical hernias often tend to enlarge faster than principal ones and may behave as incisional hernias.

An umbilical hernia has a tendency to be associated with high morbidity and mortality in comparing with inguinal hernia because of the higher risk of incarceration and strangulation that require an emergency repair. Although the number of manufactures with the title word "umbilical hernia" increased 2.half-dozen-fold between the periods 1991–2000 and 2001–2010, there even so appears to be a certain discrepancy between its importance and the attention it has received in the literature (seven). In this paper, the nature of the umbilical hernias is reviewed, and the current options for their surgical repair are discussed.

Anatomic Description

Many hernias in the umbilical region occur in a higher place or below the umbilicus through a weak place at the linea alba, rather than directly through the umbilicus itself, and the natural history and treatment practise not differ for these hernias. The European Hernia Social club nomenclature (viii) for primary abdominal wall hernias defines the midline hernias from 3 cm above to three cm below the umbilicus as umbilical hernia (Effigy 1).

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Abdominal wall hernias from 3 cm above to 3 cm below the umbilicus are defined as umbilical hernia according to the European Hernia Society Classification (8)

The borders of the umbilical canal are the umbilical fascia posteriorly, the linea alba anteriorly and medial edges of the 2 rectus sheaths on two sides. Herniation happens due to increasing intra-abdominal pressure. Predisposing factors include obesity, multiple pregnancies, ascites, and abdominal tumors (9). The content of the hernia sac may exist preperitoneal fat tissue, omentum, and modest intestine in the majority; a combination of those can have part. Big intestines are very rarely involved (10). The neck of the umbilical hernia is ordinarily narrow compared with the size of the herniated mass, hence, strangulation is common. Therefore, an elective repair after diagnosis is brash.

Anesthesia

All three types of anesthesia (local, general, and spinal) are suitable in nearly cases. The patient and surgeon should make a determination regarding the type of anesthesia to be used before surgery. Local anesthesia often provides maximum condolement for patients when information technology is accurately performed in open up repairs. Some centers routinely use local anesthesia (five, 11, 12). However, inexperience with the local anesthetic technique may crusade discomfort to patients with an increased recurrence rate. Local anesthesia may also be challenging if the patient is obese and hernia is big and/or recurrent (13). In patients with ASA I or II scores and who accept one of the specific difficulties above, the surgeon should better choose general anesthesia to feel more secure because the quality of repair is the most of import outcome measure out.

Laparoscopic ventral hernia repair generally requires general anesthesia with endotracheal intubation. Furthermore, information technology can be feasible under spinal anesthesia with depression-pressure CO_two pneumoperitoneum (xiv).

Antibiotic Prophylaxis

Naturally, bellybutton is not a clean anatomical part of the body. The umbilical skin may non be cleaned of all bacteria fifty-fifty with the utilize of modernistic clarified solutions. Therefore, the surgical site infection tin can be more frequent post-obit umbilical hernia repairs than that following inguinal hernia repairs. A ten% superficial wound infection rate is not surprising even after routine safety antibiotic use. A recent study reported a 19% infection charge per unit post-obit open umbilical hernia repair (15). Kulacoglu et al. (v) reported iii% wound infection rate with antibiotic prophylaxis with cefazolin sodium that is administered 30 min earlier peel incision.

Deysine (14) recommended topical gentamicin in improver to preoperative intravenous prophylaxis to lower the infection rates afterward hernia repairs. He reported no surgical site infections in hernia surgery subsequently setting this prophylaxis combination for 24 consecutive years. Although gentamicin is most constructive against gram-negative leaner, it is also effective against staphylococci. Furthermore, it has been stated that gentamicin can demonstrate antimicrobial synergy with cefazolin for a more successful antibacterial effect (xvi).

Which Repair Technique?

There are mainly two repair options for umbilical hernias: suture and mesh. Simple master suture repair can be used for small-scale defects (<2–3 cm). The technique of overlapping abdominal wall fascia in a "belong-over-pants" manner was described by William Mayo (17) and remained the virtually renowned surgical technique for a long time. In that location are few clinical studies with Mayo technique in the literature (half-dozen, 12). High recurrence rates up to 28% have been reported (ten).

Prosthetic materials are widely used today in the repair of all kind of intestinal hernias. Arroyo et al's (18) randomized clinical trial revealed that the recurrence rate was lower after mesh repair than that after suture repair (1% vs. eleven%) in a 64-calendar month mean postoperative follow-up. In a retrospective clinical series of 100 patients, the recurrence rates for the suture and mesh repair groups were 11.5 and 0%, respectively (p=0.007), with similar results in the infection rates in favor of mesh repair (19). A systematic review and meta-assay by Aslani and Dark-brown (twenty) revealed that the apply of mesh in umbilical hernia repair results in decreased recurrence and similar wound complexity rates compared with tissue repair for main umbilical hernias. However, many surgeons nonetheless make his/her decision on the basis of the size of the umbilical/paraumbilical defect. Dalenbäck (21) suggested a tailored repair and stated that suture-based methods for defects <two cm can provide acceptable recurrence rates (6%) in long-term follow-upwards. A postal questionnaire study from Scotland revealed that surgeons preferred mesh repair for defects >5 cm, whereas similar preference rates for suture and mesh repairs were obtained for defects <2 cm (22).

Meshes can be placed via both the open and laparoscopic approaches. Surgeons in general prefer the most familiar technique or comply with the patients' preferences. Open onlay mesh placement is the easiest technique; however, it requires subcutaneous dissection that may cause seroma or hematoma and somewhen result in surgical site infection in some cases. Mesh tin can also be placed in a preperitoneal or sublay position (five, 11). This may require more surgical experience and skill just avoids all-encompassing subcutaneous dissection and reduces seroma formation and possibly consequence in less recurrence. Onlay and sublay mesh placement can be done at the aforementioned fourth dimension in complicated or recurrent cases to provide more than reinforced repair. Some authors prefer leaving fascial margins without approximation; however, suture closure earlier onlay mesh or after preperitoneal mesh is recommended.

Furthermore, mesh plug repair was described for umbilical hernias. It can be performed with local anesthesia (23, 24). Nonetheless, in that location is no controlled study to compare plug repair with other techniques. Also plug repairs take the chance of migration and enterocutaneous fistula germination (25).

Laparoscopic umbilical hernia repair has been good since late 1990s (26, 27). Unmarried-port repairs have as well recently been reported (28). Laparoscopic technique is basically a mesh repair; however, laparoscopic primary suture repair without prosthetic material has also been experienced (29). In contrast, Banerjee et al. (30) compared the laparoscopic mesh placement without defect closure with laparoscopic suture and mesh in a clinical study and reported a slightly lower recurrence rate in the latter group, particularly for recurrent hernias.

Today the utilization of laparoscopy for umbilical hernia repair remains relatively low in the globe. Laparoscopy is preferred in just a quarter of the cases (31). In that location are a few studies comparing open and laparoscopic repairs for umbilical hernias. Curt-term outcomes from the American College of Surgeons National Surgery Quality Improvement Programme recently revealed a potential subtract in the full and wound morbidity associated with laparoscopic repair for elective primary umbilical hernia repairs at the expense of longer operative time and length of hospital stay and increased respiratory and cardiac complications (32). In their multivariate model, subsequently controlling for body mass index, gender, the American Guild of Anesthesiologists class, and chronic obstructive pulmonary illness, the odds ratio for overall complications favored laparoscopic repair (OR=0.60; p=0.01). This difference was primarily driven by the reduced wound complexity rate in laparoscopy group.

The Danish Hernia Database did not reveal significant differences in surgical or medical complication rates and in take chances factors for a thirty-twenty-four hour period readmission betwixt open and laparoscopic repairs (33). After open repair, independent risk factors for readmission were hernia defects >2 cm and tacked mesh fixation. Later on laparoscopic repair, female gender was the simply independent risk factor for readmission.

Obese patients with umbilical hernia incorporate a special group. A recent comparative study by Colon et al. (34) stated that laparoscopic umbilical hernia repair should be the preferred arroyo in obese patients. They establish a pregnant increase in wound infection rate in the open up mesh repair group when compared with the laparoscopic procedure (26% vs. 4%; p<0.05). They observed no hernia recurrence in the laparoscopic group, whereas the open group had four% recurrence rate. In contrast, Kulacoglu et al. (5) demonstrated that obese patients also require more local coldhearted dose in open mesh repair.

A summary of current repair options for umbilical hernias are presented in Tabular array 1.

Tabular array 1.

A classification of current repair techniques for umbilical hernias

A. Prosthetic repairs

1. Open approach

a. Onlay mesh

b. Sublay/Preperitoneal mesh

c. Mesh plug

d. Bilayer prosthetic devices

2. Laparoscopic arroyo

a. Inlay mesh

b. Defect closure and mesh placement

B. Tissue–Suture repairs

1. Primary suture

2. Mayo repair

Which Mesh?

Standard polypropylene mesh is the nigh frequently used prosthetic textile particularly in open up onlay repairs. Lightweight macroporous meshes are also in use. Both types of meshes are suitable for onlay and sublay placement. Reducing the density of polypropylene and creating a "light weight" mesh theoretically induces less strange body response, results in improved intestinal wall compliance, causes less contraction or shrinkage of the mesh, and enables ameliorate tissue incorporation; however, their clinical advantages have not been conspicuously documented (35).

Newer bilayer prosthetic devices are designed for open intraperitoneal inlay placement. They have two sides, i is polypropylene and the other side is a non-adherent cloth to face viscera. Two tails that are connected to the bilayer patch were sutured to fascial edges to avoid migration. Promising early results have been reported; notwithstanding, these prostheses are expensive, and prospective randomized comparative studies have not yet been conducted (36–38). It has been reported that recurrence later on this kind of bilayer prosthesis is college in comparing with that after classical sublay mesh placements mayhap because of the less controllable mesh deployment (39).

Bilayer polypropylene or partially reabsorbable meshes accept likewise been used for umbilical hernias. They comprised one sublay and ane overlay patch with a connector to eliminate migration. However, clinical outcomes after repairs with these devices take non been widely documented (40).

Choice of mesh appears to exist more important for laparoscopic repairs (41). Composite meshes are preferred materials in most institutions to avoid the gamble of visceral adhesion into the mesh (42, 43). At that place are numerous composite or dual-side meshes in the marketplace; the results of the clinical and experimental studies testing their forcefulness, durability, and prophylactic regarding both recurrence and adhesion germination widely differ.

Although standard polypropylene mesh is easy to find and a much more economical choice, its use in laparoscopic ventral hernia repairs, including umbilical hernias, has certain risks. Sarela (44) stated that the financial-cost to clinical-benefit ratio for the employ of expensive composite meshes is unquantified and is probable to remain every bit such considering given the widespread acceptance of composite products, a randomized clinical comparison with uncomplicated polypropylene mesh is unlikely to occur. In selected circumstances, it may be acceptable to use a simple mesh if this can be completely excluded from bowel past interposition of omentum; however, a composite mesh should be considered equally the current standard of care.

Factors Influencing Recurrence

Several factors have been responsible for recurrence after umbilical hernia repairs. Even so, few studies presented an contained factor after multivariate analysis.

Big seroma and surgical site infection are classical complications that may result in recurrence. Obesity and excessive weight proceeds following repair are obviously potential risk factors. The patient's BMI >thirty kg/yard² and defects >2 cm have been reported as possible factors for surgical failure (45). Moreover, smoking may create a risk for recurrence (46).

Ascites is a well-known risk factor for recurrence. Traditionally, umbilical hernia in patients with cirrhosis and with uncontrolled ascites was associated with significant bloodshed and morbidity and a significantly greater incidence of recurrence (47). However, recent reports for elective repair are more than promising, and there is trend to perform elective repair to avoid emergency surgery for complications associated with very high mortality and morbidity rates (48, 49). Early elective repair of umbilical hernias in patients with cirrhosis is advocated considering the hepatic reserve and patient's condition (50). Ascites control is the mainstay of post-operative management.

CONCLUSION

Mesh repairs are superior to non-mesh/tissue-suture repairs in umbilical hernia repairs. Open and laparoscopic techniques accept almost similar efficacy. Local anesthesia is suitable for pocket-sized umbilical hernias and patients with reasonable BMI. Antibiotic prophylaxis appears to provide depression wound infection rate.

Footnotes

Peer-review: This manuscript was prepared by the invitation of the Editorial Board and its scientific evaluation was carried out past the Editorial Board.

Conflict of Interest: No conflict of interest was declared past the authors.

Fiscal Disclosure: The authors alleged that this study has received no financial back up.

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